Provider Demographics
NPI:1124833900
Name:VITAL SOURCE HOME CARE PROVIDERS LLC
Entity type:Organization
Organization Name:VITAL SOURCE HOME CARE PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:COLLETTE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-492-9437
Mailing Address - Street 1:1401 W FORT ST UNIT 441846
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-3575
Mailing Address - Country:US
Mailing Address - Phone:313-492-9437
Mailing Address - Fax:
Practice Address - Street 1:18945 FIELDING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2511
Practice Address - Country:US
Practice Address - Phone:313-492-9437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-10
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty